Tanishah Nellom MSPH, MHA, CPHQ SCAHQ September 9, 2016 Hospital QAPI Tanishah Nellom MSPH, MHA, CPHQ SCAHQ September 9, 2016

Presentation Objectives Introduction to hospital QAPI standards and worksheets Understanding the regulatory requirements of QAPI Planning a system level QAPI program Implementation journey at Palmetto Health

Introduction to Hospital QAPI

What is QAPI? QAPI is the merger of two complementary approaches to quality, Quality Assurance (QA) and Performance Improvement (PI). Overarching Goal: Data-driven, proactive approach to improving the quality of life, care, and services in healthcare settings. Forward-thinking, preventive, proactive.

QAPI Process Facilitates a multidisciplinary, systematic performance improvement approach to identify and pursue opportunities to improve patient outcomes and reduce the risks associated with patient safety in a manner that embraces the mission of your hospital.

Purpose of QAPI Provide a formal mechanism that utilizes objective measures to monitor and evaluate the quality of services provided to patients. Closes identified gap in current PI project documentation process Formal, ongoing source of system level PI process information for leadership Meets CMS and JCO regulatory requirements

Worksheet History October 14, 2011 CMS issues a 137 page memo in the survey and certification section that was pilot tested in hospitals in 11 states Memo discusses surveyor worksheets for hospitals by CMS during a hospital survey Addresses discharge planning, infection control, and QAPI (performance improvement) May 18, 2012 CMS published a second revised edition and pilot tested each of the 3 in every state over summer 2012 November 9, 2012 CMS issued the third revised worksheet Final ones issued November 26, 2014

Final Surveyor Worksheets Made Public 11/26/2014: Day before thanksgiving “Via this memorandum we are making the worksheets publicly available. The hospital industry is encouraged, but not required, to use the worksheets as part of their self-assessment tools to promote quality and patient safety.” Worksheet Memo

QAPI Worksheet QAPI worksheet is 15 pages (CMS), JCO 14 pages Used for validation survey or certification survey in hospitals by CMS Used by State and federal surveyors on all survey activity in assessing compliance with the CoP Hospitals are encouraged to use the worksheet as part of their survey self-assessment toolkit

QAPI Worksheet Recommendations Some of the questions asked on the worksheet might not be apparent from reading of CoPs Use the worksheets as a communication device helps to clearly communicate to hospitals what is going to be asked in these 3 important areas Identify and communicate gaps Pull together a team to complete the form in advance as a self assessment Attaching the completed assessment documentation and P&P to the worksheet

CMS Resources Regulations were first published in 1986 Tag number 0001 through 1164 and PI starts at tag 263 QAPI 482.21 Questions: to CMS at hospitalscg@cms.hhs.gov CMS regulations are first published in the Federal Register then the Interpretive Guidelines and Survey Procedures Hospitals should check this website once a month for changes Survey and Certification Info

System Level QAPI Implementation

QAPI CoP “The hospital must develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS.” (Rev. 105, Issued: 03-21-14, Effective: 03-21-14, Implementation: 03-21-14)

Conditions of Participation The hospital must develop, implement, and maintain an effective, ongoing, hospital‐wide, data‐driven quality assessment and performance improvement program Scoring Procedure: The QAPI program covers each of the following elements: Development (6.1, 6.3) Implementation (6.2.a, 6.3) Maintenance (6.2.a-b) Effectiveness (3.1.k-m, 5.10.d-f) Ongoing (5.2.a-d, 5.3, 5.5) Data‐driven (3.1.a-j, 4.1, 4.2, 4.5, 5.5, 5.8) Hospital wide (4.2, 4.3, 4.4, 5.5, 5.10.a-c) Contract services Improved outcomes (5.1.a-c, 5.5, 5.6, 5.8) Reduction of medical errors (5.1.a-c, 5.5, 5.6, 5.8)

Executive Responsibilities §482.21(e) Standard: The hospital’s governing body, medical staff, and administrative officials are responsible and accountable for ensuring the following: An ongoing program for quality improvement and patient safety is defined, implemented, evaluated, and maintained; That the hospital‐wide QAPI efforts address priorities for improved quality of care and patient safety The annual determination of the number of distinct improvement projects That clear expectations for safety are established That adequate resources are allocated for improving and sustaining the hospital's performance and reducing risk to patients.

Executive Requirements Evidence for Review Determine priorities regarding which processes to monitor with data collection and the subsequent development of planned improvement efforts Review the governing body mission, bylaws, annual report and meeting minutes to determine the requirement was met. GB must provide clear expectations for safety and for allocating adequate resources for measuring, assessing, improving, and sustaining hospital’s QAPI and patient safety program The hospital has staff trained to perform QAPI activities. The hospital ensures adequate time is devoted to the quality program. The facility has a multidisciplinary, hospital‐wide Quality Committee w/ representatives from the Med Staff and hospital leadership. QAPI related education is provided to staff, leadership, Med Staff, and the Governing Body The medical staff and administrative officials must be held accountable for the implementation of an effective QAPI program consistent with GB direction that demonstrates a sustained improvement in patient outcomes and a reduction in medical errors. The Quality Committee is responsible for the development and implementation of an ongoing QAPI program that measures performance, analyzes data, and implements strategies for the purpose of improving health outcomes and reducing risk. The hospital‐wide QAPI activities identify and implement strategic actions to improve the quality of care and patient safety. These strategic actions are periodically evaluated to ensure the strategies implemented have been effective The Quality Committee reviews reports from all departments and services, discusses opportunities for improvement, and recommends corrective actions. Quality Committee minutes memorialize quality activities and corrective actions.

Data‐Driven Processes Ongoing program that shows measurable improvement in evidence-based indicators for improved health outcomes and reduction of medical errors. §482.21(a)(1) Measure, analyze, and track quality indicators, adverse patient events, and performance metrics that assess processes of care, hospital service and operations. §482.21(a)(2) The program must incorporate quality indicator data including patient care data, and other relevant data (QIO, Premier, Navient)

Data Requirements Evidence for Review The goal of the QA program is to identify and reduce medical errors and improve outcomes. The documented scope of the QAPI program is to identify and reduce medical errors and improve health outcomes. Specifies the quality indicators that will be measured, analyzed, and tracked on an ongoing basis. The documented focus of the QAPI program is to identify high‐risk opportunities and take action to reduce errors. Performance indicators and data collection activities for: Every department and service Every contracted service All departments and service lines have performance indicators All contracted services that impact patient care have performance indicators in the contract Frequency and detail of data collection activities The governing body has specified the frequency and detail of data collection Methods to monitor the effectiveness and safety of services and quality of care The hospital has a process for measuring, analyzing, and tracking quality, adverse patient events, and other aspects of performance The plan to use data collected to monitor the effectiveness and safety of services Data is analyzed to identify patterns and trends. Data is used to monitor the effectiveness of services provided. Approval of the annual Quality Plan by the governing body. The annual Quality Plan has been approved by the governing body and documented in GB minutes and Quality Committee minutes.

Performance Improvement Projects §482.21(d) Standard: As part of its quality assessment and performance improvement program, the hospital must conduct performance improvement projects. All departments, service lines, and contract services that impact patient care should participate in PIP System level Information Technology projects that are intended to improve patient care, safety, or outcomes can be used as a QAPI project. The hospital must document PI projects, the reason for implementation, and associated performance metrics A QIO cooperative project, or the hospital’s own projects are required to be of comparable effort.

PIP Requirements Evidence for Review The number and scope of the distinct performance improvement projects is proportional to the scope and complexity of services provided The annual Quality Plan identifies the data‐driven, distinct performance improvement projects to be addressed during the current year The hospital has evidence that it has conducted annual performance improvement projects The hospital has a process to document each performance project, including: 1. Reason for selecting the project 2. Initial baseline data to support the project 3. Ongoing data that demonstrates progress for each project 4. Timelines for each phase of the project 5. Data to support sustained improvement The hospital documented the required elements for each distinct performance improvement project Documentation of the progress of installation and implementation of Information Technology (IT) Systems as a hospital‐wide QAPI activity If the facility implemented an Information Technology (IT) project, determine why it was considered a priority. Is the project monitored to ensure desired outcome A hospital is not required to participate in a QIO cooperative project but its own projects are required to be of comparable effort. Determine if the hospital works with the QIO or they have a similar project that meets the requirement

Patient Safety Standard §482.21(a)(1) : The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors. The hospital must measure, analyze, and track quality indicators The hospital must measure, analyze, and track adverse patient events Other aspects of performance that assess processes of care, hospital service and operations. Standard §482.21(a)(2): Patient Safety activities must Track medical errors and adverse patient events Analyze their causes Implement preventive actions and mechanisms that include feedback and learning throughout the hospital.

Patient Safety Requirements Evidence for Review The facility implements a database for tracking medical errors and adverse patient events by category. Determine that the hospital measures, analyzes, and tracks: Quality and performance indicators Medical errors Adverse patient events Through data analysis, the facility determines patterns, implements strategies, and monitors the effectiveness of corrective actions implemented. Determine that the hospital has implemented improvement mechanisms, based on data analysis, to reduce medical errors and adverse patient events. The review of errors shall involve the individual(s) directly involved as well as representatives of any involved hospital services There is documented evidence of event reviews of adverse patient events and medical errors The annual QAPI Plan, which clearly establishes expectations for safety, is approved by the governing body. The governing body has clearly established expectations for safety.

Contract Services Standard: Is there evidence of PI review for contracted services for clinical care Services performed under contract are performed in a safe and efficient manner Contractors furnish services that meet the hospital CoPs and standards for contracted services Includes shared services and joint ventures Includes services related to patient care such as environmental cleaning, sterilization, laundry, lab, pharmacy Identify quality problems and ensure monitoring and correction of any problems ensure corrections sustained

Contract Services Requirements Evidence for Review The same level of care must be provided to patients whether you provide the service directly or through contract services Governing Body must make sure the contractors furnish services that meet the hospital CoPs and standards for contracted services Services performed under contract are performed in a safe and efficient manner Documented evidence of PI monitoring and review of contract services For each contract placed under corrective action, the hospital has a process to document each improvement project, including: 1. Reason for selecting the project 2. Initial baseline data to support the project 3. Ongoing data that demonstrates progress for each project 4. Timelines for each phase of the project 5. Data to support sustained improvement The hospital documented the required elements for each distinct performance improvement project Track and monitor all contractors that provide services that impact patient care List of all contractors providing services that impact patient care along with current PI metrics

The Palmetto Health Journey

QAPI Implementation to Date December 2014 Aware of QAPI worksheet Started inventory of QA and PI tools currently in use March 2016 Submit draft of QAPI program to QC that reflect TJC standards Introduce A3 documentation concept January 2015 Started inventory of all QI/PI projects at PH Started self-assessment process using CMS surveyor worksheet May 2016 Prepare for presentation to the PH BOD for official endorsement of QAPI plan Update QAPI inventory March 2015 Initial presentation to Quality Committee to introduce changes to QAPI requirements June 2016 QAPI plan officially endorsed by the BOD quality subcommittee and system level BOD April 2015 Had a baby July 2016 Presented to and endorsed by Operations Cabinet, Executive Cabinet, Nursing Leadership Recommendations made to QC on contracts management standards Distribute A3s August 2015 Started initial QAPI program draft Began earliest drafts of QAPI tools August 2016 Begin contracts management QAPI work Continue to train team members on A3 template use December 2015 Submitted first draft of QAPI Plan to SQIC Next Steps Build comprehensive PI education plan integrating QAPI tools with LEAN processes Getting newly formatted annual quality report approved by the BOD Assisting PI teams with developing and completing A3s Knock the next survey out of the ballpark! January 2016 Julie gives me a copy of TJC QAPI worksheet Life is now complete

Path to Implementation Committee QAPI Role (CMS/JCO) Requested Action Quality Subcommittee of PH BOD Governing Body, accountable for creation of QAPI program Endorsement of formal QAPI management plan CEO and Executive Cabinet Accountable for QAPI program effectiveness Set and communicate clear expectations for safety and quality for the system Senior Quality Integration Council Managing Body Develop, implement, and evaluate QAPI management plan Medical Executive Committee Medical Staff Leadership Assist in planning and implementation of QAPI Patient Care and Safety Physician PI Participation on PI project teams Patient Safety Leadership-Quality and Safety Council Nursing PI Patient and Family Advisory Council Patient Representation

Palmetto Health Board of Directors’ Quality and Patient Safety Committee Senior Quality Integration Council Corporate Quality and Patient Safety Performance Improvement Teams Authorizes the establishment of this performance improvement program as the Governing Body Assures: Program for quality improvement and patient safety is defined, implemented, and maintained That clear expectations for safety are established Adequate resources are allocated That a determination of the number of distinct improvement projects is conducted annually Empowered by the Governing Body to development, implementation, and evaluation of this program Responsible for monitoring and improving the quality of care, safety and service provided by its medical staff May delegate to existing entities in their respective organizational structure(s) CQPS aids in the facilitation for improving the quality of care, safety, and service provided by medical and organizational staff. Develops structures and processes to carry out this responsibility The organization will undertake efforts to improve existing processes and outcomes by forming interdisciplinary PI Teams to manage change Improvement teams will utilize the IHI Performance Improvement Model to design, implement, manage, and sustain improvement

Questions?